Documentation

A medical record should be generated for each medical encounter, with the type of record based on the severity of the complaint. An officially sanctioned event form should be used to record the encounter date and time, patient's name, sex, age, race, medical complaint, drug allergies, and relevant medical history and examination findings. The tentative diagnosis and treatment plan should be documented, complete with discharge instructions. Because all patients provided ALS care will be transported to a hospital, the transporting EMS patient care report form can conveniently document the continuum of care provided at the scene and in transit.

As with every quality medical care system, treatment at mass gatherings should be evaluated systematically to improve care at subsequent events. The medical director should review all medical records. If the patient volume was large or included a MCI, a multidisciplinary audit committee should perform the review.

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